C H A P T E R

26

Ureteral and Kidney Stones

Jorge A. Soto

ETIOLOGY
Renal calculi are typically caused by crystallization of
supersaturated stone-forming materials in the urine.
Calcium, in the form of calcium oxalate, calcium phosphate, and calcium urate, is the most common stoneforming material. Uric acid is the second most common
component. Numerous other less common components
include xanthine, cystine, struvite, as well as precipitation
of medications such as the protease inhibitor indinavir
sulfate in persons infected with human immunodeficiency
virus (HIV). Alternatively, renal pathology may initiate
crystal formations within the renal tubules that are
extruded into the renal collecting system to undergo
further growth. Urinary stasis secondary to chronic
obstruction or reflux, urinary pH abnormalities, and
chronic infections may also contribute to stone formation.
Ureteral calculi are most commonly renal calculi that have
passed distally into the ureters.

PREVALENCE AND EPIDEMIOLOGY

Nephrolithiasis and ureterolithiasis represent a significant
cause of urinary obstruction and abdominal pain. Infections, such as pyelonephritis, pyonephrosis, or renal
abscess, may complicate stone disease and may be difficult
to differentiate clinically. Imaging evaluation is usually
necessary to confirm the diagnosis of stone disease and to
detect possible complications.
The lifetime risk of forming renal stones differs in
various parts of the world: it is 1% to 5% in Asia, 5% to 9%
in Europe, and 13% in North America. The composition
of stones and their location in the urinary tract, bladder,
or kidneys may also significantly differ in different countries. Renal stone disease is slightly more common in
males than in females and in whites than in blacks. Stones
in the upper urinary tract are related to lifestyle and are
more frequent among affluent people, those living in
developed countries, and in those with diets high in
animal protein. A high frequency of stone formation

occurs among hypertensive patients and among those

with a high body mass index.

CLINICAL PRESENTATION
Nephrolithiasis and ureterolithiasis present as often severe
colicky pain in the region of the flanks that may radiate
into the groin, especially with distal progression of the
stones into the ureters. Nausea and vomiting, costovertebral angle tenderness, and hematuria are commonly
present with obstruction of a ureter with urinary calculi.

PATHOPHYSIOLOGY
The vast majority of patients with symptomatic renal or
ureteral stones seek medical attention because of flank
pain caused by acute ureteral obstruction. The most
common location of the stone is in one of the three areas
of narrowing in the course of the ureter: the ureteropelvic
junction, the pelvic brim as the ureter crosses into the
pelvis, and the ureterovesical junction.

IMAGING

Radiography
On abdominal radiographs, nephrolithiasis may be identified as focal calcific densities projecting over the renal
shadows.1 The expected course of the ureters should be
analyzed for evidence of ureteral calculi. Also, bladder
calculi may be identified on plain radiographs. In patients
with a known history of renal calculi who have undergone
lithotripsy, plain radiographs may be used to evaluate for
residual renal or ureteral calculi. When multiple ureteral
calculi are identified after lithotripsy, this is termed steinstrasse, the translation of this German term being stone
street.
Although CT has replaced the intravenous pyelogram
(IVP) in the vast majority of patients, some institutions still
185

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P A R T T W O l Nontraumatic Acute Abdomen

n FIGURE 26-1 A, Coronal reformatted image of axial CT data demonstrates a dense stone within the middle area of the left ureter. B, A slightly
more posterior reformatted view than in A shows the dilated collecting system and proximal ureter.

perform IVP for this indication. In acute ureteral obstruction, the IVP demonstrates delayed transit of contrast
medium through the affected kidney, with delayed images
showing the dilated collecting system and the site of the
obstructing stone.1 The main disadvantage of IVP, in addition to the requirement of iodinated contrast material, is
the potential delay in diagnosis from having to wait for
the delayed radiographs.

CT
Typically, renal stone CT protocols are acquired without
the use of oral or intravenous contrast media, which may
obscure the underlying stones. CT has a high diagnostic
accuracy in the detection of renal and ureteral calculi and
may be used to differentiate among stones of various
chemical composition.1-7 Recently, ultra-low-dose CT with
a radiation dose equivalent to a kidney-ureter-bladder
(KUB) radiograph has been shown to be sufficiently diagnostically accurate in evaluating renal and ureteral
calculi.8,9 The most common forms of renal stones are all
readily identified by routine CT techniques (Figs. 26-1 and
26-2). However, urinary stones formed by crystallized protease inhibitors used for HIV therapy are more difficult to
identify on CT (Fig. 26-3).
Secondary CT signs of acute ureteral obstruction
include enlargement of the kidney (Fig. 26-4), which often
demonstrates diffusely decreased attenuation secondary
to edema, perinephric stranding, as well as dilatation of
the ureter and collecting system (see Figs. 26-1 and 26-2).
Stones are most commonly evident in the three areas of
ureteral narrowing: the ureteropelvic junction, the pelvic
brim, and the ureterovesical junction. Ureteral stones may
demonstrate a soft tissue rim sign surrounding the calculus (Fig. 26-5), distinguishing a ureteral calculus from
adjacent pelvic vein phleboliths. Large intrarenal stones
occupying most of the renal pelvis and some of the
calyces, known as staghorn calculi, can also be seen on
CT (Fig. 26-6). CT may also show renal parenchymal calcifications in cases of nephrocalcinosis (Fig. 26-7).

n FIGURE 26-2 Distal right ureteral stone with hydroureter

demonstrated on a coronal reformatted CT image.

MRI
Occasionally, ureteral or kidney stones may be detected
on MRI examinations. On T2-weighted (typically breathhold half-Fourier acquisition single-shot turbo spin-echo
[HASTE]) images, stones typically appear as low-signal
intensity foci partially or completely surrounded by the
high signal fluid in the dilated collecting system and/or
ureter.10-14 However, differentiation between an obstructed
ureter secondary to a stone and the physiologic dilatation
of the ureter and collecting system commonly seen in

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C H A P T E R

26

l Ureteral and Kidney Stones

187

n FIGURE 26-5 Axial CT image shows bilateral ureteral stones. There

is a small crescent of soft tissue partially surrounding the right ureteral

stone known as the soft tissue rim sign.

n FIGURE 26-3 Coronal reformatted CT image shows

hydronephrosis and hydroureter on the right side with a distal ureteral

stone. The stone is only slightly hyperattenuating relative to the urinefilled ureter. The patient was undergoing therapy with indinavir for HIV
infection.

n FIGURE 26-6 Staghorn calculus. The CT image demonstrates a

large calculus occupying most of the collecting system of the right

kidney.

n FIGURE 26-4 Axial CT image demonstrates an enlarged right

kidney with hydronephrosis, secondary to a distal ureteral stone (not

shown).

pregnancy during the second and third trimesters may be

difficult.

Ultrasonography
Ultrasonography is often employed in patients presenting
with acute renal failure. Renal calculi are echogenic foci
that typically demonstrate posterior acoustic shadowing.1,15-17 Also, signs of hydronephrosis and hydroureter

n FIGURE 26-7 Noncontrast CT image shows calcifications within

the pyramids of both kidneys. Nephrocalcinosis was secondary to

medullary sponge kidney in this patient. Parenchymal calcifications can
be associated with ureteral stones.

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P A R T T W O l Nontraumatic Acute Abdomen

presence of bilateral jets of urine arising from the ureteral

orifices rules out significant obstruction. MRI has little role
in the evaluation of ureteral stones. IVP has little role at
institutions where rapid access to CT is available (Table
26-1).

Classic Signs
n

Radiography: calcified stone

CT: soft tissue rim sign
n Ultrasonography: intraureteral echogenic focus with hydroureter and hydronephrosis
n

DIFFERENTIAL DIAGNOSIS

may be identified on ultrasound images in patients with

acute obstruction. Proximal and distal ureteral stones may
be clearly identified on ultrasonography, but bowel gas
usually obscures a large part of the ureter; therefore, the
sensitivity of ultrasonography for ureteral calculi is significantly less than that of CT. Peristaltic activity of the patent
ureter creates ureteral jets in the urinary bladder, and
these can be readily identified with color Doppler imaging.
The presence of bilateral ureteral jets excludes high-grade
ureteral obstruction.

Acute ureteral obstruction secondary to an impacted

stone should be differentiated from pyelonephritis, acute
diverticulitis, and other gastrointestinal causes of acute
abdominal pain as well as from acute gynecologic conditions, including ectopic pregnancy and rupture or torsion
of ovarian cysts. Depending on the specific clinical presentation, ureteral stones can mimic a ruptured abdominal
aortic aneurysm, aortic dissection, renal or splenic infarction, acute cholecystitis, or acute pancreatitis.
If all the signs of acute ureteral obstruction are present,
including direct visualization of the stone, the diagnosis
can be made with certainty in the vast majority of cases.
However, if the stone has already passed at the time of CT
imaging, findings may be confused with acute pyelonephritis or other causes of acute obstruction. On plain
radiographs and CT scans, calcifications in the pelvis are
very common. Phleboliths typically have a radiolucent
center. Calcified atheromas can usually be localized to the
wall of an arterial branch. The soft tissue rim sign is most
useful for making a confident diagnosis of a ureteral stone
on CT.

Imaging Algorithm

TREATMENT

n FIGURE 26-8 Delayed phase of the contrast-enhanced CT scan

(coronal reformatted image) demonstrates the dilated right ureter and

a distal obstructing stone.

Overall, CT is the preferred method when a diagnosis of

ureteral stones is suspected. When a calcification cannot
be classified confidently as a ureteral stone, excretory
images after intravenous contrast are useful to delineate
the stone and the obstructed ureter (Fig. 26-8). Ultrasonography is useful as a screening modality because the

Medical Treatment
Obstruction in the absence of infection can be managed
with analgesics and hydration. The stone will likely pass
if its diameter is smaller than 5 to 6mm (larger stones are
more likely to require surgical measures).

TABLE 26-1 Accuracy, Limitations, and Pitfalls of Modalities Used in Imaging of Ureteral and Renal Stones
Modality

Accuracy

Limitations

Radiography

Sensitivity 70%

Does not assess degree of obstruction

CT
MRI
Ultrasonography

Sensitivity 92%-98%
Insufficient data
Relatively insensitive

Function not evaluated

Time consuming
Operator dependent

Pitfalls
Calcifications can be confused with phleboliths or
gallstones.
Stones and phleboliths may be difficult to differentiate.
Interpretation can be difficult.
Bowel gas often precludes evaluation of the pelvic region.

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C H A P T E R

Surgical Treatment

l Ureteral and Kidney Stones

189

What the Referring Physician Needs to Know

The primary indications for surgical treatment include

persistent pain, uncontrolled infection, and persistent
obstruction. Extracorporeal shock wave lithotripsy is the
least invasive of the surgical methods of stone removal.
Approximately 85% of urinary tract calculi that require
treatment are currently managed with lithotripsy. Ureteroscopic manipulation of a stone is the next most commonly
applied modality. Often, a ureteral stent must be placed
after this procedure to prevent obstruction from ureteral
spasm and edema. Other options include percutaneous
nephrostolithotomy and open extraction.

S U G G E S T E D

26

Where is the stone located?

How large is the stone?
n Is there associated obstruction?
n Is there associated infection?
n

KEY POINTS
n

CT is the preferred imaging method for diagnosis of acute

ureteral obstruction.
n CT is highly sensitive for urinary calculi.

R E A D I N G S

Chen MY, Scharling ES, Zagoria RJ, et al. CT diagnosis of acute flank pain
from urolithiasis. Semin Ultrasound CT MR 2000; 21:2-19.
Dalrymple NC, Casford B, Raiken DP, et al. Pearls and pitfalls in the
diagnosis of ureterolithiasis with unenhanced helical CT.
RadioGraphics 2000; 20:439-447.
Goldman SM, Sandler CM. Genitourinary imaging: The past 40 years.
Radiology 2000; 215:313-324.
Heidenreich A, Desgrandschamps F, Terrier F. Modern approach of
diagnosis and management of acute flank pain: review of all imaging
modalities. Eur Urol 2002; 41:351-362.
Novelline RA, Rhea JT, Rao PM, Stuk JL. Helical CT in emergency
radiology. Radiology 1999; 213:321-339.

Sandhu C, Anson KM, Patel U. Urinary tract stones: I. Role of radiological

imaging in diagnosis and treatment planning. Clin Radiol 2003;
58:415-421.
Smith RC, Levine J, Rosenfeld AT. Helical CT of urinary tract stones:
epidemiology, origin, pathophysiology, diagnosis, and management.
Radiol Clin North Am 1999; 37:911-952.
Tamm EP, Silverman PM, Shuman WP. Evaluation of the patient with
flank pain and possible ureteral calculus. Radiology 2003;
228:319-329.
Vieweg J, Teh C, Freed K, et al. Unenhanced helical computerized
tomography for the evaluation of patients with acute flank pain. J
Urol 1998; 160:679-684.

R E F E R E N C E S
1. Yilmaz S, Sindel T, Arslan G, et al. Renal colic: comparison of spiral
CT, US and IVU in the detection of ureteral calculi. Eur Radiol 1998;
8:212-217.
2. Smith RC, Rosenfield AT, Choe KA, et al. Acute flank pain: comparison of non-contrast-enhanced CT and intravenous urography. Radiology 1995; 194:789-794.
3. Smith RC, Verga M, McCarthy S, Rosenfield AT. Diagnosis of acute
flank pain: value of unenhanced helical CT. AJR Am J Roentgenol
1996;166:97-101.
4. Preminger GM, Vieweg J, Leder RA, Nelson RC. Urolithiasis: detection and management with unenhanced spiral CTa urologic perspective. Radiology 1998; 207:308-309.
5. Smith RC, Verga M, Dalrymple N, et al. Acute ureteral obstruction:
value of secondary signs of helical unenhanced CT. AJR Am J Roentgenol 1996; 167:1109-1113.
6. Boridy IC, Kawashima A, Goldman SM, Sandler CM. Acute ureterolithiasis: nonenhanced helical CT findings of perinephric edema for
prediction of degree of ureteral obstruction. Radiology 1999;
213:663-667.
7. Boridy IC, Nikolaidis P, Kawashima PA, et al. Ureterolithiasis: Value
of the tail sign in differentiating phleboliths from ureteral calculi at
nonenhanced helical CT. Radiology 1999; 211:619-621.
8. Paulson EK, Weaver C, Ho LM, et al. Conventional and reduced
radiation dose of 16-MDCT for detection of nephrolithiasis and ureterolithiasis. AJR Am J Roentgenol 2008; 190:151-157.
9. Tack D, Sourtzis S, Delpierre I, et al. Low-dose unenhanced multidetector CT of patients with suspected renal colic. AJR Am J Roentgenol 2003; 180:305-311.

10. Regan F, Kuszyk B, Bohlman ME, Jackman S. Acute ureteric calculus

obstruction: unenhanced spiral CT versus HASTE MR urography and
abdominal radiograph. Br J Radiol 2005; 78:506-511.
11. Reuther G, Kiefer B, Wandl E. Visualization of urinary tract di
latation: value of single-shot MR urography. Eur Radiol 1997; 7:
1276-1281.
12. Regan F, Bohlman ME, Khazan R, et al. MR urography using HASTE
imaging in the assessment of ureteric obstruction. AJR Am J Roentgenol 1996; 167:1115-1120.
13. OMalley ME, Soto JA, Yucel EK, Hussain S. MR urography: evaluation of a three-dimensional fast spin-echo technique in patients with
hydronephrosis. AJR Am J Roentgenol 1997; 168:387-392.
14. Sudah M, Vanninen R, Partanen K, et al. Patients with acute flank
pain: comparison of MR urography with unenhanced helical CT.
Radiology 2002; 223:98-105.
15. Patlas M, Farkas A, Fisher D, et al. Ultrasound vs CT for the detection
of ureteric stones in patients with renal colic. Br J Radiol 2001;
74:901-904.
16. Sheafor DH, Hertzberg BS, Freed KS, et al. Nonenhanced helical CT
and US in the emergency evaluation of patients with renal colic:
prospective comparison. Radiology 2000; 217:792-797.
17. Fowler KAB, Locken JA, Duchesne JH, Williamson MR. US for detecting renal calculi with nonenhanced CT as a reference standard.
Radiology 2002; 222:109-113.

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